Healthcare Provider Details

I. General information

NPI: 1295788396
Provider Name (Legal Business Name): ROBERT JOSEPH ANSELMO R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 11/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5943 W MONTROSE AVE
CHICAGO IL
60634-1629
US

IV. Provider business mailing address

5943 W MONTROSE AVE
CHICAGO IL
60634-1629
US

V. Phone/Fax

Practice location:
  • Phone: 847-508-3197
  • Fax: 716-558-1765
Mailing address:
  • Phone: 847-508-3197
  • Fax: 716-558-1765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number051033758
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: